Does Anything in Health Management Work?
by Scott MacStravic
Reports are coming more frequently that employers as well as health insurance plans are striving to get employees to take greater responsibility for their own health. These payers are assessing employees’ health, referring those found to have unmanaged risks or diseases to intervention programs, in order to prevent events that cause both high expenditures for sickness care and high levels of absenteeism and presenteeism. Investments in such programs have increased dramatically in recent years, as employers both recognize the advantages of offering health benefits and the need to minimize the costs of such benefits.
In a recent story about such efforts, citing a report by the Center for Studying Health System Change, the associate director of this Center was quoted as saying that: “There is no evidence yet that employers get a return on their investment.” [“Growing Number of Employees Face Quizzes About their Health” Newark (NJ) Star Ledger, Oct 9, 2007] In the Center’s earlier report on the continuing crisis in healthcare costs, it came to the same conclusion: “But whether the so-called health care consumerism movement can produce results – improved health care and cost savings – remains to be seen.” [D. Draper & P. Ginsburg “Health Care Cost and Access Challenges Persist” Issue Brief No. 114 Center for Studying Health System Change, Oct 2007]
Now I would be the first to agree that the evidence on EHM ROI levels is mixed, at best. Most of the published reports on the subject come from EHM vendors or their clients, both of whom are: 1) unlikely to report negative results that makes them look inept; and 2) often somewhat loose and optimistic in their measurement of ROI, for similar reasons. But to say there is “no evidence” is far from accurate, and the question of whether EHM can produce results, indeed whether it has done so, is by no means one that simply “remains to be seen”.
Studies have found that the majority of employers who have invested in EHM have not even measured their ROI, for example, much less employed rigorous scientific analysis of random controlled trials. [[J. Dresang “Exercise May Be Good Business” Beacon Journal, July 9, 2007 & K. Capps & J. Harkey “Employee Health & Productivity Management Programs: The Use of Incentives” IncentOne.com 2007]
For one thing, random control trials are not quite an employer thing. They may well pilot test an EHM program, for example, but generally they want to get as many willing participant as possible in order to find out if something works, and while they risk self-selection bias in their results, they may feel this is a built-in factor in EHM participation to begin with. And they may not wait a “decent interval” to complete a multi-year comparison of control vs. intervention group participants to see if savings not only arise, but increase over time, as most of the few multi-year studies have found. [G. Stave, et al. “Quantifiable Impact of the Contract for Health and Wellness” JOEM 45:2 2003 109-117]
I recall an attempt by the Wisconsin Stage Dept. of Education to gauges EHM based on a random control trial over ten years ago. It selected different school districts within the state at random, along with their employees, to participate in a particular program, while letting the other school districts’ employees serve as a control. But even before the first year of what was intended to be a multi-year study was completed, it found such significant cost savings in the “experimental group” that it rolled out the program for all school districts, letting scientific rigor take second place to stretching its budget in pursuit of its mission.
I have in my files literally hundreds of published reports of positive ROI that employers, most in the U.S. but many in the U.K. and other developed countries around the world that have gained positive ROI without even including reduced healthcare costs, since they have government health insurance taking care of those costs. Lower absences and presenteeism, dramatically reduced turnover, improved quality, customer satisfaction and loyalty, even new business revenue have been found and attributed to EHM programs overseas. In most cases, U.S. employers have focused on reduced healthcare costs alone, probably because they are both easier to measure and growing so fast.
We know that the federal government has consistently been equivocal about whether disease management (DM) works with Medicare populations. One can argue that DM is the least promising focus for EHM, however, or that chronic diseases in Medicare populations are the best place to look for even Medicare expense reductions. And CMS has set a 2% minimum savings before it even considers the fact that it might get a positive ROI from less than that, if the costs of the DM intervention are low enough.
But to “tar EHM with the same brush” makes no sense whatsoever. To say there is “no evidence” is particularly outlandish, even if the source of the quote may have high standards for what represents “evidence”. To suggest that thousands of employers and the EHM providers who serve them are somehow completely misled about the ROI they have measured in hundreds of cases, and have faith they are getting in others, is leaning toward the absurd, without any citation whatsoever of findings that consistently show no positive ROI.
Fortunately, the majority of employers are convinced, however unscientifically, that EHM delivers positive ROI, and hundreds have studies that show it well enough for them to find the results credible as well as admirable. EHM, just as is the case for DM, is not one single “treatment” whose success can be judged by any random control clinical trial. It is literally hundreds of different things, applied by thousands of businesses and providers to thousands of different health and productivity/performance risk and impairment factors, and there is no generalization one way or another that can be defended.
By coincidence, perhaps, Virginia Tech University has just received an NIH grant to study the impact of a single providers particular EHM approach to a single risk/impairment factor, overweight/obesity, in 32 sites. [“Virginia Tech Receives NIH Grant to Study the Impact of the incentaHEALTH Workplace Weight Loss Program Across 32 Sites”. It will examine employees’ productivity and healthcare costs, offering incentives for employees to participate, lose weight and keep it off, while discovering the answer to only the limited question of whether this particular EHM program works in the particular places where it is applied.
It may well be the more conservative position to take that the overall question of whether EHM yields a positive ROI has not yet been answered. But since the overall question can never be answered — i.e. since only findings of particular EHM methods applied to particular EHM challenges in particular workforces can ever be reported – it is not merely a conservative position to take, but a meaningless one. As long as there are individual EHM programs that have proven positive ROI results, that fact alone is, and properly should be the kind of answer employers are looking for.
If we ever achieve the kind of “transparency” in EHM programs and methods that we have long enjoyed with respect to sickness care (as I mentioned in my Oct 12 posting on the subject), we will still only be able to say that some work and some don’t, while the market gradually weeds out the unsuccessful in favor of the successful. But to assert a general ignorance of whether EHM works, or contend that there is no evidence that it does, performs a great disservice to both the “discipline” of EHM, and to the many employers and thousands of employees who will benefit from it, once enough employers, providers, and consumers try it. The general question will and can never be answered, by either its most vocal critics or champions.
